Indiana community health workers: challenges and opportunities for workforce development

Background An interest in, and the need for, Community Health Workers (CHWs) in the United States is growing exponentially. CHWs possess a unique ability to relate to and build trust with communities in order to improve clinical outcomes, while building individual and community capacity. Given their critical role in addressing social determinants of health, expanding the CHW workforce is crucial. However, creating CHW jobs, facilitating training and certification, and establishing sustainable financing models to support this workforce has been challenging. Methods A mixed-methods study consisting of an online survey and focus group discussions assessed the strengths, practices, and challenges to CHW workforce sustainability and expansion in the state of Indiana, including perspectives from both CHWs and employers. Results Across 8 topics, mixed data analysis revealed 28 findings that were both complementary and unique across focus group and survey results. Results highlighted CHW skills and attributes, illustrated the recruitment and hiring process, and provided insight into measuring outcomes and outputs. Findings also indicated a need to build position validation, professional development, and billing and reimbursement capacity. Conclusion Building and sustaining the CHW workforce will require creating an evidence base of roles and impact, increasing awareness of existing reimbursement mechanisms, and sharing best practices across employer organizations to promote optimal recruitment, training, supervision, career development, and funding strategies.


Background
As frontline public health workers, community health workers (CHWs) are trusted community members who have a close understanding of the community they serve [1]. This position of trust enables CHWs to serve as an essential link between health and social services and communities earning lower incomes who have been historically marginalized to facilitate access and improve the quality and cultural competence of service delivery [2]. CHWs improve clinical outcomes and build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities, such as outreach, community education, informal counseling, social support, advocacy, and community-based research and evaluation [2]. Kangovi and colleagues [3] reported a 28% reduction in hospitalizations following a CHW intervention in a population earning lower incomes with multiple chronic conditions. Ingram et al. [4] found CHWs significantly improved clinical markers Open Access *Correspondence: jgonzalv@purdue.edu 2 College of Pharmacy, Department of Pharmacy Practice, Purdue University Center for Health Equity and Innovation, 640 Eskenazi Ave, Fifth Third Bank FOB, 3rd Floor, Indianapolis, IN 46202, USA Full list of author information is available at the end of the article (i.e., glycosylated hemoglobin, body mass index, and total cholesterol) of people living with chronic diseases. Furthermore, CHWs have been shown to save state Medicaid programs $4200 per beneficiary [5], and if scaled to even a quarter of United States (US) Medicaid beneficiaries, studies show CHWs would save taxpayers $78 billion annually [5].
Given CHWs' critical role in addressing social determinants of health, including overcoming barriers to employment and financial self-sufficiency, expanding the CHW workforce is a powerful way to catalyze economic self-sufficiency in neighborhoods with incomes below the federal poverty levels. However, creating CHW jobs, facilitating training and certification, and establishing mechanisms to sustain this growing workforce has been challenging. Recently, Cacal [6] found that only 21 states in the US had legislative bills addressing CHWs and only 15 states had formalized definitions of CHWs. Establishing standardized definitions of CHWs is vital to reaching a consensus regarding CHW training, certification, and workforce development. Many states have modified the American Public Health Association (APHA) definition to enhance relevance in their communities (e.g., use of the word promotora [a lay health worker that works in a Spanish-speaking community]), which contributes to lack of clarity regarding CHW roles and titles [6]. In addition to a lack of a standard definition, there is no national consensus on CHW certification. A National Academy for State Health Policy (NASHP) survey reported only 17 states have certification pathways for CHWs. Certification is often voluntary but sometimes necessary for Medicare reimbursement [7].
In Indiana, sustaining CHW positions has been challenging due to limited funding and lack of infrastructure that fosters workforce growth and expansion. This has been due in part to poor awareness of CHWs and their roles, cost prohibitive training and certification opportunities for populations earning low incomes, and an underutilized and complex reimbursement system through Indiana Health Coverage Programs that fails to include a full range of CHW services. Despite these challenges, the employment of CHWs in Indiana is projected to grow at a rate of 14% from 2018 to 2028. With approximately 220 CHW job openings annually, this demonstrates a much faster rate of growth than the average for all occupations [8] and is associated with average annual earnings of $38,050 [9]. CHW certification in Indiana is open to anyone aged > 18 years with a high school diploma or equivalent, creating a promising employment pathway for young people and those without higher education, particularly for groups that have been marginalized [10,11]. To promote the unification of CHWs, the Indiana Community Health Worker Association (INCHWA) has developed a framework through which Indiana CHWs may become certified. Working with the Indiana Department of Health, INCHWA approves "training vendors" certified by the state to train and produce Medicaid reimbursable certified community health workers. While certification is not a requirement to practice as a CHW in Indiana, it is required to receive reimbursement from Medicaid.
CHWDI was created in 2020 in recognition of the immensely important role and expected growth of CHWs, and to address CHW workforce development challenges in Indiana. Dedicated to health equity, CHWDI's mission is to expand the Indiana CHW workforce to increase access to health and social services for under-resourced communities while also increasing employment opportunities for community members. Thus, to inform CHWDI's statewide initiatives in Indiana, the objectives of this study were to conduct a statewide needs assessment to 1) characterize the current CHW workforce landscape, 2) describe CHWs' experiences with training, certification, scopes of work, job security, career development opportunities, and community priorities, and 3) explore employers experiences in hiring, training, and supervising CHWs, current challenges and potential areas of needed training and development activities, and funding mechanisms to sustain or expand CHW employment opportunities.

Methods
Utilizing a concurrent, multimethod approach [12], all aspects of this study, including the initial design, were informed though diverse stakeholder engagement. Specifically, in collaboration with INCHWA, a steering committee was established which included 25 members from public health and social service government agencies, academic institutions, and other key community stakeholders. The steering committee was convened to provide essential insight that will continuously inform the implementation, evaluation, and long-term sustainability of the institute's efforts. This study was approved by the Purdue University Institutional Review Board (IRB; protocol IRB 2020-1468) and the review deemed this study exempt. Informed consent was obtained verbally by all participants prior to commencing research activities as approved by Purdue University's IRB.

Data collection instrument development
The research team and steering committee collaborated to identify objectives pertaining to data collection instrument development (i.e., survey, focus group questionnaire). Both quantitative and qualitative data collection instruments were framed by 13 pre-defined overarching topics (see Appendix).

Quantitative instrument development
An initial survey was created by the research team, with feedback from the steering committee and INCHWA to ensure appropriate content and consistent language leading to minor modifications (e.g., providing additional response options and language clarity for intended audience and adding questions for additional contact-related information from participants) and four items added. The final 59-item survey sought to establish a demographic profile of Indiana CHWs, identifying CHW job titles, roles, employment sectors, and activities, as well as to capture CHW certification and training prevalence, and collect demographic information of communities and populations that Indiana CHWs serve.

Qualitative instrument development
Concurrent with survey development, focus group data collection instruments followed a similar process as that of the survey. With the goals of receiving CHW and employer input related to the CHW workforce and gaining a greater understanding of strengths and challenges of the workforce and CHW roles, two semi-structured focus group guides (Appendix) were developed. Specifically, one guide was developed for CHWs and a separate guide for employers of CHWs.

Quantitative data collection and analysis
In November 2020, an online survey of Indiana CHWs was conducted through use of an anonymous Qualtrics survey link distributed through INCHWA. Respondents could forward the link to additional CHWs. The survey remained open for 4 weeks. Only CHW respondents that indicated that they were based in Indiana were included in data analysis. Additionally, to eliminate potentially duplicative and fraudulent responses, researchers excluded responses from identical internet protocol (IP) addresses and email stems, that took 5 minutes or less to complete (minimum survey completion time of 10 min based on the estimated time to complete the survey), and that were less than 50% complete. SPSS software (Version 26) was used to descriptively analyze data (i.e., frequencies, counts). All eligible survey participants received a $10 e-gift card.

Qualitative data collection and analysis
Focus group participants were recruited through INCH-WA's mailing lists, with all interested participants able to engage via Zoom videoconferencing software. Focus groups were facilitated by members of the research team over a four-week period in November-December 2020, with each focus group lasting between 75 and 105 min. All participants received a $45 e-gift card as compensation for their time. All focus groups were recorded verbatim and transcribed using Otter.ai software. Research assistants completed a quality check of each transcript to ensure accuracy prior to data analysis.
NVivo 12, a qualitative software, [13] was used to deductively and inductively analyze data to identify emergent topics [14,15]. First, using the focus group guide a codebook with 13 pre-defined topics was developed and deductive coding was carried out. Next, an inductive analysis was conducted to further refine the pre-defined topics as well as add new topics to the qualitative codebook [15,16]. Throughout the deductive and inductive analysis, coding consisted of identifying direct quotes that represented each topic and organizing these quotes, or raw data, into findings by topic while succinctly combining quotes into broader topics [6,14]. Researchers met to review and discuss findings and any discrepancies were resolved through discussion [17].

Mixed data analysis
To identify areas of concordance among data sources, survey and focus group data were triangulated using a data consolidation analytic approach [18,19]. This approach blends qualitative and quantitative data to investigate a phenomenon, thus corroborating internal validity of findings [20]. Microsoft Word and Nvivo 12 ® [13] software were used to compare and consolidate findings via cross-tabulation of quantitative and qualitative findings by each of the pre-defined and inductively derived topics.

Results
A total of 1804 survey responses were received with 1156 responses excluded due to not meeting inclusion criteria (see Methods section). A total of 648 responses were eligible for analysis. See Table 1 for demographics of survey respondents. Four total focus groups were conducted with participants representing 25 different organizations throughout Indiana. Two focus groups were conducted with CHWs (N = 7 and N = 7) and two with employers (N = 9 and N = 7). Across 8 topics, mixed data analysis of survey results and focus groups revealed 28 findings (Table 2). Overall, 6 (21%) findings were complementary and supported by both quantitative and qualitative data sets, 20 (71%) findings were unique to focus group results, and 2 (7%) findings were unique to survey results. There was no observed divergence of results between the two data sources ( Table 2). The 8 topics are detailed below with both quantitative (survey) and qualitative (focus groups) results presented within the respected topic.

Topic 1: who are community health workers?
Quantitative analysis of survey results revealed that Indiana CHWs are highly diverse with 43 countries and 14 languages represented (Table 1). CHWs are employed under various titles (Table 3) and in various employment sectors and settings, including Social and Community Services (24%), County Health Departments (15%), and Private health sectors (13%) ( Table 4). CHW services are provided throughout Indiana's 92 counties and triangulated data supported existing literature [21,22] that CHWs serve clients who face a myriad of economic, social, physical, and environmental challenges (Tables 2  and 5).

Topic 2: attributes, roles, and responsibilities
CHWs and employers both described key CHW attributes, characteristics, roles, and responsibilities, six of which aligned with the national CHW Core Consensus (C3) Project, which aims to increase visibility and a greater understanding of CHWs [23]. Following a post-hoc qualitative analysis, these nationally recognized C3 qualities, roles, and skills were mapped to our Topic 2 findings in Table 2. CHWs are often motivated by their "want to work with a lot of people [from] different backgrounds" and from the community they serve, or they leverage their own lived experience to connect and relate with clients. CHWs view themselves as trusted members of the community who actively work to create and keep this trust, "…it's usually just a matter of them [clients] getting to know and trust you. " CHWs acknowledged that trust could be difficult to build but described qualities they possess that allow them to effectively   Survey results revealed 11 job titles held by CHWs (see Table 3 for CHW job titles) in addition to CHWs representing XX employment sectors and setting (see Table 4). Health-related topics covered by CHWs (see Table 6), include the most common focus area, chronic disease management (13%). Specific chronic diseases that CHWs focus on include high blood pressure (7%), obesity (5%), diabetes (3%), asthma (2%), kidney disease (2%), COPD (1%), Alzheimer's (1%), arthritis (1%), and high cholesterol (< 1%).

Topic 4: Certification and Training
11. Benefits of certification CHW certification provide legitimacy and validation and offers CHWs the opportunity to strengthen their overall skill-base. "It was a good…certification…just to kind of let people know in the community I've been doing this for a while. I'm a CHW, and I'm focused on what's going on in the community. " -CHW "The benefit to us for the community health worker certification, though, for our licensed Indiana navigators, that it just gives them another layer of competence. So as people contact us, you know, seemingly that they just need health coverage, but they might also need to be connected to the application for food stamps, or you know, other things. It's just kind of this multi layered interaction with people and so that's the benefit to us. "-EMP Unique: Focus Groups (CHW & EMP)

Certification training programs and preferences
CHWs were introduced to certification and encouraged to become certified by their employers and felt that the in-person training was positive, provided opportunities to network, and was preferred. "I did the weeklong in person, and it was a ton of information. I felt that it could have at least been a good additional 2 days. It was just so much. " -CHW "     The potential for CHWs to "train-up" into a supervisory role and group and one-on-one supervision models were discussed. CHWs also described characteristics of an ideal supervisor as someone who has done the work of a CHW and is supportive.   A key CHW role is the ability to "serve as a resource for people that I come in contact with. " As such, they often become a point person for their clients or "that one consistent face and voice that [clients] could contact. " They view "knowing the resources that we have in the community [as] very important" as it strengthens their capacity to connect clients to needed medical and social services. As trusted resources, CHWs often advocate for change, "I'm a health advocate, here at the hospital we have all kinds of projects. Our goal is to break those barriers [experiences by clients, such as] why people sit in the ER forever, you know, constantly, they can't afford their medications, utilities…just can't get to the doctors…the transportation. " In addition to linking clients to resources, CHW responsibilities involve providing case management, offering health programming, and working with clients to set health and wellness goals. Survey results revealed that CHWs work within a wide breadth of health-related topics with chronic disease management being a key focus (13%) ( Table 6).

Topic 3: recruitment and hiring
Employers shared ways that hired CHWs enhanced their organizational work as "there was so much that our registered nurses and dietitians and registered respiratory therapists couldn't complete…so CHWs were hired to help us close those gaps. " When hiring future CHWs, employers looked for professionalism, flexibility, and organizational and communication skills. Employers also expressed a preference for bilingual candidates with an existing connection to the focus community, "We really try to hire from within that community. So we're getting people who know the community, they know the resources, they know people coming into the clinic. " During the hiring process, employers reported turning to organizational leadership, community partners, and currently employed CHWs. Successful CHW hiring strategies included drafting clear job descriptions, recruiting directly from client populations, hiring CHW cohorts for group training and onboarding, and providing employee benefits.

Topic 4: certification and training
After analysis, among the CHWs surveyed, over 80% (n = 526) reported being certified, more than 50% (n = 368) found CHW employment as a result of certification, 12% (n = 75) had a CHW position before becoming certified, 5% (n = 35) did not find CHW employment, and 6% (n = 40) did not seek CHW employment. Participants shared that certification provided CHW work with legitimacy and validation, "being certified as a CHW, just kind of gives us that little bit of …, I guess, upper level, you know what I mean?" Certification also seemed to offer CHWs an opportunity to strengthen overall skills, knowledge, and training, "…it's just good to have that [training] knowledge and background and experience to add to what we do every day. " Surveyed CHWs shared an unawareness of certification when they entered the workforce but were asked to complete certification by their employer. Most (n = 492; 76%) CHWs reported employers paying for the CHW certification; employers use state-funded training and workforce development reimbursement programs to do so. However, employers shared inconsistencies in terms of sponsors, certification type (e.g., combined CHW/ Certified Recovery Specialist [CRS], stand-alone CHW certification), and cost, "… it [certification] was kind of expensive… it was even more money than just doing the whole CRS/CHW program. So I think that could deter some people from becoming CHWs. " Both CHWs and employers expressed being confused by the different certification programs as some are recognized by the certifying state agency while others are not. They also shared frustration over the lack of clear guidance related to which certification-CHW versus CHW/CRS-is approved for reimbursement. Participants expressed a strong preference for in-person trainings over online versions as it provided an opportunity to connect and network with other CHWs and "…to help with engaging and just the motivational interviewing skills. I mean, there's some things that you can't learn by using the computer and doing virtual. " While most agreed, some described the required week-long training as quite intensive and suggested that the in-person training be extended or spread across a longer time-period.

Topic 5: job satisfaction and challenges
Making a difference in people's lives was described as a rewarding aspect of CHW work when "you can see how you affected them or how, you know, you're even able to make them believe in themselves, which is huge. " Being recognized by the medical team was also seen as rewarding: "I feel like the medical team really recognize after, you know, they definitely are thankful and appreciative of the help that we provide. " Despite the rewards, CHWs continue to face challenges due to a general lack of awareness of who the CHW workforce is and what they do, which "...a lot of the time with CHWs, I think that what we do is not valued. So we don't really get paid that amount that we should get paid. " CHWs also described barriers such as a lack of resources to help the vulnerable people they serve, which can exact heavy physical and emotional costs. CHWs discussed ways to address these challenges including creating "more acceptance of what we do and being more respected as a profession because this is a profession. "

Topic 6: measuring impact
Both CHWs and employers identified a need to document the impact of CHW work because "…you help that one person today, you did just a little something for somebody here and there. Over time, that's going to add up to big success. " CHWs expressed wanting to be involved in defining and measuring this impact and suggested that metrics to include (e.g.; established community relationships, resource provision to clients, programmatic benchmarks, enrollment goals). Employers agreed a need exists to document CHW impact that supports return-on-investment (ROI) to justify current and future CHW hiring lines. Employers shared various client-and program-level metrics used to track CHW efforts (e.g.; community outreach events conducted, completed screening tools, number of goals set/achieved with clients, changes in knowledge gains, follow-up rates). Employers also discussed community-specific indicators, such as emergency room utilization rates, changes in public safety calls, number of jobs created, and greenspaces developed/improved. Additionally, they explained that metrics from existing registries and assessments are used, such as electronic medical record (EMR)based registries, Recovery Inventory, Star, Strength and Risk Assessment, Child and Adolescent Needs and Strengths and Adult Needs and Strengths Assessment (CANS/ANSA) state tools, and Insight Vision. Despite these existing approaches, employers agreed that efforts are needed to standardize current tools, reporting systems need to align with existing EMR systems, measures are needed across the social determinants of health, and systems created to build evaluation capacity.

Topic 7: supervision, professional development, and peer support
Being relatable, supportive, and familiar with CHW work were identified as characteristics of an ideal supervisor, "I need a supervisor who does this job... And I want someone who has done the work to be able to 'train up' others and also be that lead... " Related to professional development, CHWs expressed wanting access to supervisor encouraged and funded trainings and certifications that go beyond initial CHW certification, but shared that professional development opportunities are not readily available and costs fall upon the CHWs themselves. CHWs shared interest in on-the-job training in particular areas (e.g., home visits, and going into homes), and access to annual conference or annual/quarterly trainings in order to stay current in the field and learn from peers. CHWs also expressed concern over lack of career advancement pathways, "so within the organization, there are not too many [promotions]. " Despite the absence of professional advancement, CHWs expressed a desire to expand their current position to include supervision and training of other CHWs, "I would like to teach the classes as well as even after going through the course, inquired about how to become an instructor. " CHWs expressed a strong interest in connecting with other CHWs in person at their workplace and through annual conferences. They described INCHWA as playing a key role in providing CHW peer support by engaging CHWs via email, huddles, and webinars, "I do find the INCHWA emails and newsletters to be helpful…that's really the only connection that I have to anyone else. " They also felt that INCHWA's efforts to advocate for the profession were needed and appreciated.

Topic 8: funding and reimbursement
CHW positions are primarily funded through county, state, and federal grants or soft-monies and, to a lesser degree, by institutional or hard-money leading to concerns related to job security, "We work for a not for profit, so things change all the time. Funding could go at any moment... " Both employers and CHWs shared how soft-money funded programs place employees at risk for unexpected terminations: "…their [CHW] grant was from the Office of Minority Health, they really hated it because it got pulled in year three and they had made so much progress…I'm staying away from grants because you can't trust them. The work they did was so valuable…so it was really sad they couldn't finish. " Participants expressed confusion and lacked understanding related to CHW billing for Medicaid reimbursement. They shared concern regarding the sustainability of a business model that relies on the current CHW reimbursement structure given that it does not allow for billing of clients with a diverse payer mix, does not provide payment for CHW services provided on the same day as other provider services, and fails to cover a broad spectrum of CHW services, "But I think that insurance companies like Medicaid and SSI would benefit in the long run, if they covered more of the services CHWs do because they're all services that keep their patients, their customers in compliance. " Both CHWs and employers agreed that applying for CHW reimbursement through Medicaid is cumbersome, confusing, and complex, "…it would be nice to see more guidance on what's considered appropriate within those ranges…it's hard to get a concrete understanding of what's a part of that CHW service definition. " Employers discussed the potential of Z code usage, and that more effective collaboration among doctors, providers, and CHWs would be needed to address these challenges, "…if our doctors or providers would work closer together, and they would look through the curriculum with me, we could work as a partner, and I could educate, educate the group and get reimbursed for his patients. "

Discussion
With growing evidence of the clinical and social impact of CHWs in communities that are underserved, there is an increased national demand for CHWs. Despite this, some US states continue to face challenges related to funding, training, expanding, and sustaining their CHW workforce [24]. Engaging key stakeholders from multiple perspectives and utilizing a multi-methods assessment approach provided invaluable insight into the strengths, needs, and landscape of the CHW workforce in Indiana. These collaborative efforts positioned us to prioritize actionable recommendations. Research findings demonstrated the strengths and diversity of Indiana CHWs and informed the authors' four key recommendations for expanding and sustaining Indiana's CHW workforce. These recommendations are transferable to other states with similar contexts and can be implemented sequentially or concurrently with no prescribed order (Fig. 1).

Recommendation 1: standardize, build, and maintain a database on the roles and impact of CHWs in Indiana
Scaling and sustaining CHW positions is best facilitated through accessible information documenting the roles, responsibilities, and impact of CHWs. Clearly defining CHW roles to healthcare providers allows for better CHW integration into healthcare organizations, improving overall health outcomes [6,25]. Maintaining an Indiana CHW registry will allow compilation of up-to-date statistics on workforce density, geography, certification levels, areas of work, employment, and income. With standardized data collection across employer organizations, it is possible to measure the full impact of CHW services and demonstrate ROI, as well as establish standardized and sector-specific metrics for CHW outputs and outcomes. Ingram et al. [4] described the use of electronic health records to examine the effect of CHW services on chronic disease outcomes. The Arizona Community Health Worker Association and the CHW Workforce Coalition spent 2 years gathering data from and about CHWs and community health representatives serving American Indian Tribes and communities via small group sessions and annual meetings. These data later informed a formalized assessment of CHW mastery of core competencies as well as a process to approve training programs throughout the state [26]. Our recommendation to build and maintain an up-todate evidence based CHW registry and database could serve as a more efficient approach to collecting data, and meaningfully build upon the mounting evidence of positive health outcomes associated with the integration of CHWs into patient care across the country [3][4][5][27][28][29][30][31][32]. These standardized data can be used to inform and catalyze advocacy and policy efforts towards creating and/or refining standardized state training programs, pathways for certification, employment, and sustainable funding for the CHW workforce.

Recommendation 2: disseminate evidence and educate employers and communities about the CHW profession to advocate for CHW workforce integration and expansion
Dissemination of evidence can be more easily achieved upon establishment of the evidence-based database (Recommendation 1), which could inform the development of dissemination products, such as informational materials and strategies, and can equip all applicable stakeholders with increased clarity and understanding of the CHW profession, associated roles, and impact on health outcomes. The National Association of Community Health Workers (NACHW) document resource center is one example of data dissemination, which is accessible on the NACHW website for free and includes study reports, policy briefs, fact sheets, and more from researchers and CHW organizations across the country [33]. In accordance with Sabo et al. [24], we recommend that evidence be distributed in lay language and accessible through a variety of outlets (e.g., social media, newsletters, workshops, interactive presentations at staff meetings), in the preferred language of the focus community. Communities who understand the role of CHWs will be more trusting of the profession and are better poised to leverage CHW services. Employers who know the demands of the job are also in a better position to take the steps to adequately support the workforce [34]. Yearly reviews and pre-and post-program implementation analyses are vital in promoting workforce development. Frequent data analysis and dissemination of organizational-level CHW impact metrics will support evidence-based advocacy for the workforce. Impact metrics can include the number of enrolled patients, client evaluation forms, follow-up rates, and community-specific indicators such as a reduction in emergency room use [2]. The C3 Project, which aims to increase visibility and a greater understanding of CHWs, created a publicly available CHW assessment toolkit. The toolkit allows for field-oriented, evidencebased recommendations and resources that aid in the holistic assessment of CHW impact [23]. Similarly, our recommendation supports creating and disseminating informational products that are readily accessible and can demonstrate the positive impact that CHWs have on their communities, thus, leading to opportunities for increased funding, expanded policy initiatives and resources for employing and retaining CHWs.

Recommendation 3: facilitate understanding and promote access to and utilization of existing funding mechanisms for CHW workforce sustainability and expansion
An underutilized and misunderstood billing framework for reimbursement of CHW services leads to a lack of sustainable funding for permanent CHW positions. Inconsistent funding jeopardizes CHW recruitment and retention, as well as program implementation. Ensuring sufficient funds through extensive cost analyses that consider expenses associated with continued training, sufficient supervision, and integration of CHWs into healthcare systems is vital [34]. There are various CHW funding strategies to be explored, including reimbursement for non-clinic based CHWs, and leveraging existing state workforce development programs. Our study findings suggest that the existing Medicaid reimbursement policies in Indiana require improved clarity and employer education to increase appropriate utilization [2]. Ibe et al. [35] concluded that more research needs to be conducted to gain a better understanding of CHW certification and its' impact on patient health outcomes. Similarly, further research on the role of CHW certification in supporting the financial sustainability and workforce development of CHWs in the US is warranted.
A well-maintained evidenced-based CHW database (Recommendation 1) could facilitate advocacy efforts regarding reimbursement rates to be commensurate with the impact of CHWs and better alignment with similar position policies (i.e., Certified Recovery Specialists). Furthermore, the current public health climate due to the Coronavirus Disease 2019 (COVID-19) pandemic has generated additional federal funding mechanisms for CHW career paths. A more recent avenue of federal funding is the increased public health workforce funding through the Centers for Disease Control and Prevention (CDC). As of March 2021, the CDC planned to provide $300 million towards CHW services to support COVID-19 control and prevention and an additional $32 million towards training, technical assistance, and evaluation of CHWs [36]. President Biden's plan included increasing the CHW workforce by 150,000 nationally and pledged to provide direct grant funding, as well as add CHW services as an optional benefit for states through Medicaid [37]. States can better maximize the sustainability of the workforce as funding opportunities arise to revise existing regulations around CHW reimbursement.

Recommendation 4: share CHW workforce models and best practices across employer organizations to optimize strategies
Fragmented CHW employment pathways and lack of career development opportunities can lead to missed opportunities, stagnant wages, job dissatisfaction, and high turnover rates. These can be mitigated by the creation of standardized, sector-specific guidance for optimal recruitment, integration, training, and ongoing education, certification, supervision, career development, and funding of CHWs for employers in Indiana. The National Committee for Quality Assurance (NCQA), in partnership with the Penn Center for Community Health Workers, is a multistakeholder effort to create such standards nationally. The goal of the NCQA standards is less about dictating CHW training methods or scope of practice and more about providing evidence-governed guidelines for the systems in which CHWs work [38]. Involving CHWs at all levels of decision-making related to the workforce will streamline communication across CHW employer organizations, state agency partners, and other stakeholders to align statewide efforts. Yearly reviews of national CHW models and standards should be conducted to remain aligned with best practices outside of Indiana and coordinate with efforts already underway (e.g., APHA-CHW section, NACHW). Demonstration projects can allow for the development of context-specific guidance to help integrate CHWs and scale up workforce models into organizational strategic plans, teams, and workflows across the state.

Limitations
There were several limitations to this study. While our steering committee guided our work, participants of the focus groups did not capture all potential stakeholders (e.g., unemployed CHWs, policy makers, and national organizations who work with CHWs). A disproportionate percentage of CHWs selected "American Indian or Alaska Native" as their race/ethnicity which is inconsistent with the known demographics of Indiana. Future surveys should be created to more clearly delineate the race/ethnicity of all respondents in order to avoid this classification error. Methods taken to eliminate potentially duplicative and fraudulent survey responses as described above may have inadvertently eliminated legitimate responses. Future online surveys should utilize software features, such as prevention of "ballot stuffing". Lastly, the findings presented here are specific to Indiana and may not be generalizable to all states; thus, each state should identify unique nuances of the CHW workforce in their geographic region.

Conclusion
CHWs come from diverse cultural and linguistic backgrounds, with an existing connection and relatability to the focus community-valued attributes and characteristics by employers. Through their knowledge base, skills, and social networks, CHWs excel at serving as an essential conduit for locating and connecting clients with both social and medical resources which leads to reduced health disparities and improved individual and community health outcomes. A high need for CHWs exists across community and clinical settings; however, employers often lack the ability to obtain and sustain proper funding to meet this demand. Despite a growing CHW workforce, a consistent foundation and understanding of CHW positions and capabilities is lacking. Creating consistency and a greater understanding regarding CHW models, measures, evidence-based practices, funding and reimbursement policies, and training and certification is crucial to optimize strategies and build workforce capacity locally and nationally.